SÉGOU, Mali -- The Ségou bus station, not far from the aquamarine waters of the Niger River, is a bustling transportation hub ringed by small shops and a colorful sea of traders carrying wares to market. It is also home to the only program that provides contraceptives and reproductive health services to adolescents in this small city and its surrounding rural region.
In a small but clean office on the second floor of the bus depot, two health educators greet young people who come by to ask questions, buy condoms or seek information on sexually transmitted diseases (STDs). "The office has become something of a drop-in center," says Boncana Haidara, a former midwife and now one of three professional health educators who staff the Programme des Adolescents (PRADO) office in the depot. "It is easier for a girl to tell us that she is worried about not getting her period than to tell her mother."
PRADO is an activity of the Association de Soutien au Développement des Activités de Population (ASDAP), based in the capital city of Bamako. In 1995, ASDAP became the first organization in Mali to develop contraceptive and reproductive health services targeting young adults.
Adolescents desperately needed these services, says Fatoumata Traoré Toure, ASDAP president. "We started as a pilot project for a year with support from the Centre for Development and Population Activities" (CEDPA), she says. "We trained peer educators and we found that it was an excellent approach." With support for a more comprehensive program, the effort has since been expanded to involve rural and urban zones such as Koulikoro, Koutiala and Ségou.
Girls and boys trained in counseling and other educational activities help promote contraceptive use among their peers. The program in Ségou trains two or three young people in each neighborhood it serves to become peer educators. These educators are 10 to 20 years old, and of the 65 trained so far, two-thirds are females. "Girls talk more among themselves," says Haidara, who is convinced that working through girls is the way to reach other girls, and the earlier the better.
A 1999 survey confirms that young women want to know more, earlier. "If you could change the past," the survey asked, "which information would you have wanted to have about sex?" The most common response -- by 41 percent of women surveyed -- was that they wished that as adolescents they had known better how to prevent pregnancy and STDs and cited age 12 as the appropriate age to begin receiving information. Survey participants reported that lack of information was one obstacle to reproductive health in the Ségou region; other obstacles included distance to health services, lack of contraceptive methods and cost.1
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Bocana Haidara of PRADO |
Dr. Mohamadou Hachimi, health director for the Ségou region, points to the survey as evidence that new strategies are needed to serve young adults. But he says traditional values and societal pressures for recently married girls to prove their fertility discourage formal health services from reaching adolescents effectively. "In general, it is taboo to talk to young people about sexuality or reproductive health," Dr. Hachimi says. "Here it is taken badly if you talk about family planning with young people, but we need to, considering the problems of undesired pregnancies and STDs."
Another 1999 survey in Mali, conducted by CEDPA and the Futures Group International, found that about one in every four unmarried young adults in the Ségou region reported having had intercourse at least once (23 percent of women and 27 percent of men ages 15 to 24). One in five (22 percent women, 19 percent men) reported having had a sexually transmitted infection in the prior 12 months, yet fewer than one out of 13 reported that they were currently using contraception.2 "By 18 years old, 81 percent of adolescents in Mali have already initiated sexual activity," reported a nationwide Demographic and Health Survey.3
Tea and notebooks
When PRADO peer educators organize discussion groups in their neighborhoods, they usually ask one of the three professional health educators to assist, primarily to provide support when difficult questions are posed. "They serve traditional tea with mint," Haidara explains and smiles. "ASDAP provides the tea."
Incidental expenses such as providing drinks for gatherings or gasoline for transportation can add up, and programs such as this often wrestle with issues of sustainability. To curtail expenses and provide an incentive for peer educators, PRADO encourages educators to sell condoms during discussion groups and similar events. Peer educators keep half of the proceeds for themselves, returning the rest to ASDAP. Young people who seek services in the office above the bus depot receive free counseling and pay a small fee to obtain condoms, spermicidal tablets or oral contraceptives.
Each peer educator keeps a notebook, recording useful details about home visits, discussion groups, or counseling sessions -- themes discussed, number of female and male participants, how many were younger than 25 years old. Such information helps staff strengthen and focus their assistance.
Certain health concerns, such as the health risks of female circumcision, are difficult to discuss. More than 83 percent of young women and men in Ségou report being willing to have their girl children circumcised.4 The Bamako office provides audiocassette tapes on female circumcision to help initiate discussions. ASDAP also publishes an attractive magazine on adolescent reproductive health that targets young people, and is partly written by young people.
"You have to involve adolescents in everything you do," says Traoré, the ASDAP president. "You should not propose all the strategies. Young people themselves have a lot to add. You have to know how to listen to them. Young people do not like people to tell them what to do. Involve them, listen to them. If you arrive with preconceived ideas, you will not advance."
Many components of the PRADO program are consonant with World Health Organization (WHO) recommendations on action for adolescent health. For example, WHO's framework for country programming recommends providing information in a safe and supportive environment for young people and involving youth systematically.5 The PRADO program offers young people a convenient place to access services, with both male and female educators at the bus depot office. The program is built on a framework of youth involvement, yet also sponsors events that involve parents and the community, including the school system.
"Each month we go to the schools to explain what reproductive health is," says Haidara. "First we ask, 'What do you know about AIDS?' Then we point out which of their comments are true, and we get into more detailed explanations of points that need better understanding." In this traditional ethnic Bambara town, Haidara says, the subjects of reproductive health, family planning, STDs and sexuality are taboo in family discussions. But young people are hungry for information. "Some students ask about monthly periods, consequences of abortion, STDs, and how to take pills," she says.
Haidara says being an effective health educator takes persistence and a high level of comfort in talking about sensitive issues. "I think you really have to work at continuing to communicate and raise awareness of the issues," she emphasizes. "The staff have to be very comfortable with young people and with the subject of reproductive health. Every single day you see a new face, so you have to keep working."
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Aminata Barry Touré (right) with community leaders. |
Neighborhood women
Even in Bamako, where health services are more widely available than in Ségou, there is an urgent need for adolescent services. In some neighborhoods, individual women pick up the slack, often addressing a range of needs including health, education, employment and recreation.
Aminata Barry Toure, who organizes biweekly discussion groups on reproductive health for adolescents in the Doumanzana neighborhood of Bamako, says young people need information to make responsible choices. "There is a lot of boredom," says Barry, president of the Association Malienne pour la Sauvegarde du Bien-être Familial. "Young people initiate sexual activity even at 15 or 16 years old. There are no cinemas, no places for games. There is nothing to do but have sex."
Barry is known among young people in her neighborhood for her activism. She raised funds to purchase a donkey, allowing teenagers to earn money by carting away neighborhood trash. She spearheaded the establishment of a dispensary in Doumanzana, possibly the only neighborhood clinic in Bamako with laboratory facilities and reagents to do tests for gonorrhea, syphilis and sickle cell anemia.
"Here we do not talk in the family about sexuality," continues Barry, a professional accountant and mother of six. "It is thought that if you do this, you are pushing them into making love. We think it is best if they wait until they are married. But kids are sexually active anyway. They just hide it."
It is a hot afternoon, and the dusty streets are filled with young people. Barry sends out the word, and soon a group of teenagers assembles in a simple, dirt-floored preschool her organization built for children of market women. They speak openly about sex and reveal fears stemming from both lack of information and misinformation, such as the incorrect notion that condom use can cause a woman to hemorrhage.
One student wants to know whether a woman can get pregnant if a man's preejaculatory fluid and a woman's natural lubrication touch outside the body. The young people laugh at each other's questions but listen intently to the answers. "How can you withdraw without leaving the condom inside the woman?" a boy asks. "How long does it take for a woman's fertility to return after using oral contraceptives or Depo [Provera]?" a girl asks.
Many of their questions are practical. Others address deeply ingrained cultural perceptions, such as the notion that forced sex is a matter of passion, not violence.
When a young woman says she has friends who have been raped, boys jump in and say "men cannot control themselves" and "between men and women it is fire and gas: if they get together everything catches fire!" It is clear that many of the young people in the group are aware of forced sex, and attitudes towards it vary along gender lines. Nationwide, one out of five young women reported that their first experience with intercourse was not consensual.6
"The important thing is opening the channels of communication with young people," Barry says. Not many adolescents come to the dispensary for contraception, she says, but many others seem interested in the discussion groups. Many participants purchase condoms after such talks, when she has them.
Sitting in her office, her normally cheerful face is pinched. She mentions that a young girl she knows recently died from an abortion. "The news has really hit me hard," she says. "She was so beautiful. Really beautiful."
Barry wants to create "listening centers" for young people, where trained adults and peer leaders would listen and give advice, including referrals for medical care. She envisions renting or building a youth center with a video machine and conference room where young people could get together. Perhaps if mixed groups of boys and girls learn to begin talking at an early age about relationships and how to prevent pregnancy and STDs, she muses, the stage will be set to discuss reproductive health decisions as couples.
In this context of widespread poverty and insufficient health services, women leaders such as Barry are playing an important role in identifying and filling the gaps. "Health, family planning, legal aspects of female circumcision, small commerce and income generation, gardening, the care of young children and girls, environment, reforestation," Barry lists, and sighs. "Women do everything."
-- Elizabeth T. Robinson
References
- Connaissances, attitudes et comportements des jeunes (15-25 ans) vis-à-vis de la santé de la reproduction. Unpublished paper. Ministère de la Santé, des Personnes Agees et de la Solidarité; Direction Nationale de l'Action Sociale; Centre National d'Information, d'Éducation et de Communication pour la Santé (CNIECS), 1999:27,65.
- Enquête CAP sur la santé reproductive: rapport d'analyse (version finale). Unpublished paper. The Centre for Development and Population Activities (CEDPA) and The Futures Group International, 1999:58,66,114.
- Coulibaly S, Kicko F, Moussa Traoré S, et al. Enquête Démographique et de Santé Mali 1995-1996. Bamako and Calverton, MD: Cellule de Planification et de Statistique, Ministère de la Santé, de la Solidarité et des Personnes Agées, Direction Nationale de la Statistique et de l'Informatique, and Macro International, Inc., 1996:94.
- Enquête CAP sur la santé reproductive: rapport d'analyse (version finale).
- Action for Adolescent Health: Towards a Common Agenda. Geneva: World Health Organization, 1997.
- Connaissances, attitudes et comportements des jeunes (15-25 ans) vis-à-vis de la santé de la reproduction, 35.
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